Type your answers in the form, print 3 copies, and sign.

Submit a total of 3 copies of your essay, each having this completed form stapled to the top. Essays must be one full-page.

Send it to: RARE Everyday Hero Scholarship, 27500, Cosgrove, Warren, MI, 48092

Student Information
     
First Name
 
Middle Initial
 
Last Name
 
Gender:
 
Home Address
 
City
 
State, Zip
  -
Preferred Phone
  - -
Email Address
 
Parent or Legal Guardian
 
Michigan College/University or Post Secondary School Planning on Attending:
 
     
High School Information
     
School Name
 
School Address
 
School City / Zip
  -
Teacher / Advisor Name
 
Teacher / Advisor Email
 
Teacher / Advisor Phone
  - -
     
Everyday Hero Information
     
Hero Name
 
May this person be contacted?
 
Hero's Phone Number
  - -
Hero's Email Address
 
Hero's Place of Work
 
Hero's Job/Occupation
 
Street Address of Workplace
 
City of Workplace
 
State / Zip of Workplace
  -
     
     
Please Star the industry that best describes where your hero works

Arts/Communication/Entertainment
Automotive/Manufacturing
Building/Construction

Education
Food/Hospitality
Health Care/Science

Non-profit/Public Service
Technology
Other_________________


I am confirming that the information provided is correct and accurate to the best of my knowledge and that my essay is an original document and has not in any way been duplicated from another source.
     
_______________________________________________________________
Applicant Signature
  _________________
Date
     
_______________________________________________________________
Teacher/Advisor Signature
  _________________
Date